Specialist Training Should Be Gutted.

The RVU payment hierarchy is clear. There is a discrepancy between the payment for cognitive vs procedural and surgical services. Many subspecialists like to use the argument that their training is longer and therefor their payment should be higher. 

And they are correct. They should get paid more for the longer training they experience. That's why I am proposing a change in their training that better reflects real world experience of what they have to offer me as a hospitalist (substitute internists or family medicine doc for hospitalist) or their patients.

I have yet to find a subspecialist that offers any great insight in the evaluation, diagnosis or treatment of medical conditions that exit their specialized organ of study. All medical subspecialists have always been internal medicine trained first. Whether the chosen field of expertise is cardiology, gastroenterology, allergy, infectious disease or nephrology, all of them have first completed residency in internal medicine.

The further pursuit of specialization can take anywhere from two to four additional years of training in a fellowship designed to make specialists experts in their organ of choice.

It is this specialization that has made internists turned subspecialists into subspecialists who have lost their ability to be internists. Is it possible that some medical based subspecialists can practice internal medicine? Yes, but I would guess the vast majority cannot nor would they have any desire to. They cannot because they are too far removed from the daily practice of subspecialty things to do what internists do. They don't want to because internal medicine is very complicated and involves little economic reward.

So I am here to suggest that we stop farting around by wasting everyone's time and money. Stop wasting billions of dollars of tax payer money every year. Stop wasting years of young doctors' time. I think it's time that subspecialists stop becoming internists first and go directly to their subspecialty training track, right out of medical school.

Instead of taking six years to become a gastroenterologist, (three years of internal medicine and three years of gastro) it would take just three. Cardiology? Three years. Why? Because we are all fooling ourselves if we believe that three extra years of internal medicine training adds any benefit for the vast majority of clinical patients who need specialized care. If you need a doctor to put it all together, you go to an internist. They are the ones that connect the dots. If you need a question answered about the heart, you ask for the opinion of a cardiologist. But the three years it takes for a cardiologist to learn how to manage diverticulitis is three years of wasted time and money that we just can't afford anymore.

One of my biggest pet peeves as a hospitalist is when I come to the chart the next day and find that one medical subspecialist has written a consult for another medical subspecialist. That fact that subspecialists believe only other subspecialists are capable of handling organ specific disease says to me that their understanding of the specialty of generalist medicine is gone. They have lost touch with reality. They can't understand how an internist would be capable of handling things they can't.

The same goes with the surgical subspecialties. There is no reason to train an orthopod to take out a gallbladder. If you're going to be an orthopod specializing in the hand, your entire existence should be learning about the hand. You are worthless to the general public, spending tax payer money in residency learning to replace hips if all you're going to do is carpal tunnel surgery.

I would like to believe that having a broad base of education for all physicians is helpful for patient care. But my experience with subspecialists says to me it just doesn't matter. Let's stop beating around the bush. All that extra education of generalist training that subspecialty medical and surgical subspecialists experience is a waste of everyone's time and money. Let's train them quicker. Get them out quicker. That way their argument for higher pay because of longer education disappears. Since they offer little in the way of anything outside their three year subspecialty training, we can pay them with reasonable parity.

And they can stop complaining that they deserve such a high premium for all their extended education. An education which comes at a great expense in direct tax payer training dollars and the perceived entitlement of higher reimbursement in clinical practice. A generalist education who's benefit disappears almost immediately once the cocoon of academia disappears and the first paycheck arrives from the practice of community based private practice.